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Doctor-backed Bill Would Remove UR Eligibility for some Treatment Requests

  • State: California
  • Topic: Top
  • - Popular with: Legal
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The California Senate Labor and Industrial Relations Committee will consider three workers’ co…

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Anne Bazel Nov 3, 2016 a 7:58 am PDT

SB863 was created for one purpose, to make more money for insurance industry, since they are struggling so much. Look, SCIF, the State ran company, probably less efficient than other private ones, is in a very slim surplus. Of course, they can make more.
So, SB563 would be terrible, undermining all the effort of the insurance companies to be able to inappropriate deny treatment at any time they want.

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

The Docs have got to look at this from both sides. First the carriers have a deadline to meet for UR. Secondly UR can justify the services that the Docs provide. BTW the denials for the most part legitimate with rare exception.

Anonymous Nov 21, 2016 a 10:49 am PST

I agree with workdoc. Justsaying many of the denials are not justified at all. I overturn them most of the time by providing medical records. Most injured workers do not have someone who does this. When I help other injured workers, they get their UR denials overturned as well. This tells me they should not have been denied in the first place.

Jason Bernard Nov 3, 2016 a 7:58 am PDT

But didnt we recently an article on this very site where CHSWC applauded the 90% authorization rate that carriers were showing?? No surprise then or now that practitioners see the exact opposite than what CHSWC and DIR publish as fact. I participated in this study and I'm glad to see that something became of it. Until now, CSIMS, AAOS, COA and other physician support organizations have done little to nothing but stand back and watch our fee schedule dwindle and our right to practice medicine all but disappear.

robert bruckman Nov 3, 2016 a 7:58 am PDT

WC medical fees are misunderstood. The state fee schedule specify the minimum to be paid. All fees are by contract with the payor. If anyone does not want to sign up they don't need to. If they want to demand a different fee, they can. The problem is to get around Stark regarding organized communication.

Carolyn Van Dusen Nov 3, 2016 a 7:58 am PDT

I find it interesting that all the responses involve money and not "treatment". I was under the impression that doctors became doctors to help people, but guess not. I have adjusted claims for 20 yrs in CA, OR, AZ, NV, WA, AK and only CA is this screwed up. Guess what, Adjusters hate UR also but we also dislike "treaters" that abuse the system, do nothing for the injured worker and complain that they don't get paid enough. If a treatment isn't providing results, then why continue with it? Move on, try something else. That is why the medical community wrote the MTUS and ACOEM and all the other guidelines; to provide time frames to try things and options to move on if is not showing results. Why continue to do PT if after the initial 12 visits there has been no change? How long do you want to beat that dead horse? Why are doctors shocked when after the 100th PT session it is determined not medically necessary? Everyone wants to go back to pre 2004 rules. Really? Oh wait that is where the money was! Injured workers were TTD forever, PD was based on dueling medical opinions and employers were leaving CA left and right. So if is all about the money, I hope I never get injured in CA.

Jason Bernard Nov 3, 2016 a 7:58 am PDT

Yes. Money. I have payroll. Overhead. Malpractice insurance. Medical school loans. Provide work comp coverage. Health benefits for employees. Rent. Electric bill. Liability insurance. Transcriptionist. Physician assistants. Medical assistants. IMR fees. IBR fees. Payroll tax. Etc.... As my income drops, yes I am increasingly nervous about the care that I can not provide for my patients. Longer waiting room wait times. Longer lead times on reports. Longer waits for benefit verification. What patient would want to come to my office?? Income drives quality of care. Dont agree?? Them get treated at a discount center like county hospital where fees are predetermined. Not sure that you would be happy with the environment and treatment rendered. I hold my office to higher standards.

Carolyn Van Dusen Nov 3, 2016 a 7:58 am PDT

But.. you missed the point, yes you have a business to run, but all we hear from Doctors is that their fees are cut and UR denies everything. Well we already know that 90% of all UR requests are approved. Maybe you are part of the 10% that drives all the UR/IMR or maybe your not, but the point is you complain about the system because you are not getting paid enough to provide treatment in WC, well no one is forcing you to accept WC patients. You say that applicant attorney's and doctor's lobbiest are sitting by doing nothing, but so are you. Everyone wants to point fingers to who is making the system worse or more difficult, but we all seem to forget that we are here to assist those truely injured on the job get the proper care they need and to return them to the work force.

Jason Bernard Nov 3, 2016 a 7:58 am PDT

And yet, despite being here to "assist those truly injured on the job get proper care and..." It is pulling teeth to get the proper care authorized. You're right nobody is forcing is forcing me to take wc patients vehicular is why in 2 years my wc practice has dwindled from 25% of my practice to 10%. You're also right that I do nothing but complain about the system. Mostly this is due to the fact that all complaints that I voiced in 2012 fell on deaf ears only because Safeway, Disney and Grimmwsy Farms had already infiltrated the DIR and had their way with lawmakers. Not a single doctor was included in the discussion the ultimately resulted in 863. I tried to get involved but couldn't. I sent emails to Christine Baker. I went to local public forums. I called state legislators. I sent Gov Brown office an email. Ultimately what I want from wc is to get patients better and back to work and I know I can. I have. But not being able to obtain a mri or get physical therapy authorized gets in the way of patients progress. Not to mention the countless appeals and peer to peer phone calls. Soon enough the 10% wc cases I do get in my office will be down to zero. And somehow I think that is what Safeway intended all along. Exactly why physicians or physician advocate groups were not invited to the table. Imagine drafting a bill that focuses on medical treatment and yet you don't seek the advice of medical personel.?.? sounes stupid right? Trust me,

Keith More, Esq. Nov 3, 2016 a 7:58 am PDT

First of all the case involving Travelers insurance company was my case and was no fluke. Just as the Chamber claims that medical treatment has been abused in the past, the carriers are now abusing the system and wrongfully denying medical treatment. The politically motivated Dubon ii desision needs to be overturned. These Bills need to be modified - to include "where an injured worker subjects himself or herself to the MPN the treatment recommended by the MPN doctor is not subject to UR." Additionally, the adjusters MUST comply with the Labor Code and Regs by providing ALL pertinent medical records to the UR physician so that the NON CERT is not based on "lack of documentation". The Adjuster MUST also utilize a physicain within the same field as the requesting doctor.
The DWC-1 claim form makes it a FELONY to materially misrepresent facts inorder to deny WC BENEFITS. Where an adjuster fails to submit the proper medical records or uses a family practitioner to deny a suicidal patient psych medication is FRAUD and needs to be prosecuted. The court transcript from the trial involving the NPR story is unbelievable as to what Travelers did. I recently CAUGHT a carrier NON CERTING a botox injection for a Quad when the UR PHYSICIAN had Certified the treatment. There are no checks or balances on the UR system. The MPN is set up by the Insurance Company - then the Insurance Company gets to choose any doctor in the United States to perform UR - the Insurance Co decides what medicals are to be submitted to UR - and the type of doctor to review the request. No penalties and no ramifications. In the meantime massive amounts of evidenced based medical treatment is denied.
We need the Court System to make decisions. Remember Marbury vs Madison. Checks and Balances. I am not sure when the Chamber or the drafters of SB 863 lost faith in the Judicial system and our Work Comp judges.
Sincerely, Keith More

Manila Manila Nov 3, 2016 a 7:58 am PDT

Well said. UR is so often a terrible punishment for people already hurt. It additionally is one size fits all with little to no consideration as to each patient's individual circumstance. MTUS are blindly quoted by UR reviewers (often different specialty reviewers and often nurses, not doctors) and do not take into account patients with multiple complex conditions. For instance, take a patient with chronic pain, failed low back syndrome, a Major Depressive Disorder, drug dependence and long term absence from the workplace, and per the usual UR procedure if "functional improvement" is not achieved within four initial treatment sessions, then further requests are denied. This is an impossible expectation and requirement for helping a person with problems of this size. Would the Army Corp of Engoneers be told they have 4 days to repair a dam with major faults and if not nothing else will be approved for the dam?

BILL CLABAUGH Nov 3, 2016 a 7:58 am PDT

Finally, someone saying it as it is!! Of course what the Ins does is fraud, but the state gets money from them, so it's --follow the money. I worked in this field for over 20 years and ran one of the first SIUs in the state. I helped put doctors in jail, at that time, med-legals were made up and being paid for at $1500 per. Now, it seems that the treating docs are not being paid for what they are expected to do, they don't even get paid for review of records of their patient, how do they know what's going on?? The invent of the UR is a disgrace--when is the state, and our great Democratic Governor going to work for the people? (I am a democrat) If the applicant attorneys would grow a pair and stop just accepting what they can get because, as one told me--"I have to survive", then maybe we could get this system back to where the IW can receive the proper treatment--also I believe that the IW on an accepted case should receive FULL pay, why must they suffer because of the Er carelessness or neglecting the shape of the workplace? I commend you sir, for pointing out that the things the adjuster does should fall into the same bag as the rest of the population, and when they don't follow the law, they should be treated as we all are AND MADE TO GO THRU THE LEGAL SYSTEM--ie arrest them---

JAMES BADER Nov 3, 2016 a 7:58 am PDT

I certainly agree with the comments by Keith More. What is the point of having a MPN if any request for treatment is denied ? What is the point of having a system for workers compensation if injured workers cant get medical treatment recommended by their MPN doctors on admitted injury cases? The carriers have the power to dismiss any physician from their MPN, so if there is any doctor who does not follow the whims of the insurance carrier as to length of disability, type of treatment recommended, or level of PD, they get thrown off anyway. Sounds like pure oppression to me.

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

Who told you that the MPN Docs were subject to UR?

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

I meant to say who told you that the MPN Providers were not subject to UR?

Anonymous Nov 21, 2016 a 10:49 am PST

Keith Moore you are absolutely correct. Bottom line claims adjusters are not sending relevant records to UR and it is not known at least to me if they have to. In my case, I have not once seen relevant records sent to my UR reviewer from my adjuster. In many instances medical treatment guidelines are being misused by UR and IMR to deny requests several ways, either they are quoted incorrectly or partially taken from a guideline or more commonly do not reflect the patients medical conditions. I do not know how they get the 90% approval numbers, as most of my treatment requests are denied by UR and I have to overturn them in a appeal. Other injured workers, doctors and applicant attorney's and they stated the same. Most people who are injured return to work. Could it be these denials are being done to those who have costly, more severe conditions and treatment requests?

Anonymous Nov 3, 2016 a 7:58 am PDT

Again, a few minority of extreme are driving the policy. As the numbers showed already, over 90% of the treatment requests are approved. All request first go to nurses for initial review. Majority gets approved and only those that may have some issues are sent over to the physician reviewers. Giving incentives to the physician reviewers to sway less than 10% of the request is just plain stupid. If they really wanted to save the money, they'd make the policy stricter or give incentive to the nurse reviewers who control all of the request initially. I've worked with half a dozen UR companies so far and there's never been any enticement to sway my opinion, never. There are thousands of doctors performing reviews. Where's this myth coming from anyway? And for CMA to act on it is quite ludicrous. Those complaining and screaming loudest are probably the Southern Cal comp mills that are responsible for 90% of the state liens. CMA is just listening to the mills it seems. I really hope they'd act on facts rather than accusations based on hunches...

Jason Bernard Nov 3, 2016 a 7:58 am PDT

This is the problem, you are quite certain that so cal comp mills are the majority of respondents to this CMA questionnaire. Perhaps you're right. But as a practitioner, we are also correct when we claim with absolute certainty that 90% approvals are not true!! No way. If 9 out of 10 of my requests were approved, trust me, I would not have a complain in the world. Without a doubt my patients would get the treatment that I need them to get in order to recover. In my 15 years of practice, I have NEVER had 90% approvals. Not pre899 and certainly not post863. My MRI requests are denied. My physical therapy requests, if not denied, get modified. Today, more than ever, my meds are denied. My surgery requests are denied, including one today. A torn meniscus and partially torn ACL, denied because not "enough" conservative treatment has be done. Ludicrous. No treatment in the world, no matter how aggressive or conservative will repair a tear. I asked the patient to her face "do you want surgery to fix this? How active do you want to your lifestyle to be?" Overwhelmingly yes, she wants surgery. The injury is work related and nobody is disputing that. But surgery is in fact denied. No chance that this falls in to the 10% denied category. It is quite the contrary. The most frustrating part for me as a physician od knowing I can fix this lady. I want to help her. That is why I am a dictor. Unfortunately I am not a charity. The surgery center won't do a case for free, and due to MPN issues, I will not do surgery on a lien. In this day and age I don't think anybody will.

Anonymous Nov 21, 2016 a 10:49 am PST

As an injured worker, who has been in this system a number of years I have never seen 90% approval rate in fact most of my doctors requests through the years were denied and only received on appeal. Why is it that AA's, IW's and PTP's are not seeing this 90% approval rate? I see the opposite 90% denial rate. I am curious as to what is being counted as an approval for the 90% approval rate. Are they counting office visits, and each medication separately? Is this 90% approval data available to the public with what exactly is being counted as approvals? As I have helped other injured workers attempt to appeal treatment denials, I am seeing exactly what this surgeon (response) is experiencing. MRI's and testing's are getting denied, surgery is denied most of the time and PT is denied or modified so much it is useless, and medications are being unilaterally being denied.

Anonymous Nov 3, 2016 a 7:58 am PDT

The 90% of approved treatment may well not even be actual treatment, I see requests from PTP for the next routine follow up appointments that gets approved by UR, I bet those kinds of requests are a big part of that 90%.

Anonymous Nov 21, 2016 a 10:49 am PST

I am a patient in the California workers compensation system. Before my work related injury I previously had very little knowledge of workers compensation and no idea of how difficult it was to receive medical treatment once in this system. I have tried my best to learn the rules of this system to obtain medical treatment. I have also attempted to help other injured workers navigate the system with the limited knowledge I have. It is difficult for me to understand the positive statements from DWC about what has occurred since the passage of SB863, as I have seen the opposite.

Since SB863 was passed I have seen many injured workers get all of their medications unilaterally denied through UR and IMR. These are patients who often times have older claims, with serious chronic conditions. Their medications are being denied even though they have not have not had any change of condition. Some of these patients have settled via stip and kept their claim with open medical. These patients do not understand why they can no longer receive medical treatment with their open medical, when they have a AME or QME final report that has stated these treatments and medications were appropriate and they believed part of their open medical. These patients agreed to these settlements with the understanding they would actually receive medical treatment as they did previously. Some are now getting all requests from their doctor denied, and I have seen some instances where the injured worker is denied to see their treating doctor through UR.

The injured workers who are lucky enough to have private insurance, the VA and in some cases Medicare are using those resources to get their medications after a UR or IMR denial. Those who do not have such resources are placed in horrific situations when they do not have the means to pay for their medications.

Recently, I myself had most of my medications sent through UR and denied. I did not have a change of condition at this time. I appealed the UR through the UR internal appeal process, only to find many of the records I sent for the appeal, including medical treatment guidelines was not forwarded to the UR doctor. This has happened in the past, where I sent the UR appeal directly to the UR company, only to find they were limiting what was forwarded to the UR doctor. I called the UR company and was told by a UR supervisor when this happened to me in the past why the doctor did not review or list all of the records I sent was due to my claims adjuster had control of what records I send to the UR company are forwarded to the UR reviewer, and over 50 pages had to get approval from my claims adjuster. This omitting of records stopped for a few months, but apparently they have continued to do this in my case as I recently sent around 100 pages of medical records and the UR doctor listed 3 reports sent to him. I have overturned my medication denials in the past, but not this time, as it appears the guidelines I sent were not forwarded to the UR doctor, or ignored,and records were omitted. The UR doctor used guidelines that did not fit my conditions as rational to deny. So even though I have a condition that warrants these medications, and have successfully overturned every previous UR denial for such medications, the UR company has found a way to prevent me from having a successful appeal by omitting medical records and/or medical guidelines that actually fit my condition. I will now have use my private insurance for these medications, as well as pay co-pays. I am fortunate to have this option as many others do not.

I do question if an actual doctor is doing some of these UR denials that I have read for myself and other injured workers I have tried to help. In the past I have on occasion used and sent back to UR in an appeal the same medical guidelines used to deny the original UR denial. How can this be? The UR guidelines used to deny in some instances actually showed the rational to approve the request, however they can manipulate this by taking a sentence or two and use it out of context to deny, when in fact adding the rest of the cut off sentence or additional sentences from the guideline quoted would show the request is warranted. I have seen guidelines used to deny that do not fit the patients condition, and this is the most common abuse I have seen. I have also seen UR reviews deny a request stating MTUS and chronic pain guidelines is silent on a request. They should not deny a request just because the medication or request is not covered in the MTUS or chronic pain guidelines. This is grounds for a UR complaint, but they get away with it as it as it is my understanding it is not grounds to take it to a judge.

My pain management doctor told me most of his workers compensation patients have been denied their medications. His words "they are doing this to everybody". I go to a very reputable pain management doctor, who is a Harvard graduate,has published papers on pain management, has had previous involvement with establishing treatment guidelines for pain , and has been a speaker at CAAA conventions. He is not a treatment mill and does not dispense medications from his office. He is well versed in CA workers compensation and will do peer to peer phone calls (when he is able to get a hold of the peer doctor which is another issue).He uses medical treatment guidelines in all of his requests and UR is still denying his requests. Something is wrong here.

I believe SB563 would help to stop some of these abuses. If a non appealed UR determination or IMR determination stands for a 12 month period, unless there is a change of condition or new information, then how can they send injured workers medications through UR EVERY month without the same?

I hope CAAA will lobby hard for the passage of SB563 and SB542. I know I will.

Applied Underwriters Nov 3, 2016 a 7:58 am PDT

I can't speculate on your case directly, nor can I comment on the level of your pain or treatment plan. I do think it's important though to point out that FDA regulations and guidelines, as well as Official Disability Guidelines, (which is what states are using to develop drug formularies and which I understand California is considering) are very clear on how/when pain medications should be used. You mentioned medications were denied even though there was no change in your condition...that may be the reason for the denial. Opioid medications are not intended to necessarily be long term therapy, especially if there is no change or improvement in the patients condition. Besides being highly addictive, the longer a person takes these medications, the more tolerant they become, so it will take more and more of the medication to find relief. Eventually the maximum dose will be reached, the pain will still be there, and there will be no improvement in function. These are the cases that should be required to go through utilization review...every...single...month. If a person is on opioid for a 12 month period and there is no change in condition or new information, the treatment plan should then be questioned. I am likely not telling you anything that you are not already aware of, but understand not every situation is a case of chronic pain that requires continuous pain management therapy, and yet opioids are prescribed on a regular basis for extended periods of time and for those people, it is more of delay in the healing process than actual treatment. There are more cases like this, than cases such as yours. I do not work for or represent a utilization review company. My interest is strictly in pharmaceuticals and appropriate pharmaceutical treatment. I do hope there can be a "happy medium" reached regarding utilization review.

Apr 23, 2015 a 11:04 am PDT

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Barbara Ramiller Nov 3, 2016 a 7:58 am PDT

The fact that you are going to a pain medicine doctor that presents at CAAA conventions speaks for itself. You can't say you don't go to a mill then talk about a physician that is tied into CAAA.

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